02040103 CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT 'CONTRACTOR'NFOR' Mi XFJ0N-
BUILDING ADDRESS: PERMIT NO,
761 R ShADOWHILL TA ATLAS HEATING 02040103
OWNER'S NAME: APPLICATION SUB DATE
DAUGHERTY DONALD E AND VIkGIDII 155 SAN LAZARO AVE 04/19/2002 •
PHONE SANITARY NO. CONTROL NO.
(408) 739-0516
PIN I ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB Ill
< L- i C=1 L. ) I I
0 y i LICENSED CONTRACTOR'S DECLARATION lob Description
'mal I hcrtby affirm that 1 am liccnxd under provilimm of Chapmr9 lcommencinL
:t44 withSeel;o ]000)of D;Hs;on3oflclissincss9^d rofessionsCode.anOmylicenu REPLACE FURNACE
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0 5 L;ae ata ao L;a.Y 6 S2-6
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3 O G ARCHITECTS DELLA ON
�5 1 undemand in,plans shall be uxd as public rtcoNs
ic
O O L¢ciiscd Pro@ssional C 1 N A 96nw E
R OWNER-BUILDER DECLARATION It-
I hereby o(Brm on 1 am exempt from the Conon Co Liam,Law for my
C? whicfolloh re uiresnonsa(Section]orIS,B alter. and Professions Code:Any city structure
F F O which requires a permit to mnswct,ober,improve.0permi•or repair any urvauR MAY 0 1 2002
3$-.Prior�o iu issuance,also.requimsthe epplicam for such permiuo file uiynW asamem. - -- - -. _.. - __ _______ _-
thatliiulicenxdpuisuohimcre'ysbisbnx of the Conuactoh Lianx law(Chepter9 Ss,l... �ta�pr.,�,�-0y Valuation
se that a is a with Secnofilini ppfhe bear
or the aBuamxani Pro Anyvi Code) (�'( 1 ),3'�� IIJ;�p•,'IO:V 7's.i=." 'fi'
se that M1c is exrt empt lany. riilddor.pilis ca ellljed u6cruscu Any violation -
ffrktiOfS,cneecdmmfvehumedlchlla (S30)).subjccss the opPiiam soeaivllpcnalry- N .2`:V VT Nt)
301P- 'H PLUMBI Occupancy Type
❑I.as owns of the property,or my employees with m allies as their sole compensation. 202 _ ROUGH MPC TrAT.
wins-de rite woik.'and the suudum s r imendeaen a Law done
9aaa,- 3 04 - ROUGH E8 93 gG tic
iOwner or pie Professions Code:The Contmcmro License Law dos not apply u en IlOnS"''' i."•'°
rotcry,
Owner thl phis,. employe.provided t e toth and rwho does m.1 int needhimslf
or F INAL_,$LECTRI CAL.-.-
completion,
AL
_or cred�fM1 M1ix own emPloyas.provided Nat sucM1 improvements ere hm intended or --_--.____,_ 5A.5_._=.
,comple f 'sthe.If.however the boldine mpm,mein is the
linin one year or 507 — FINAL PLUMBING
eomRl t ,the owner-Wilder line will have the tureen of proving IM1nI he ala tut bulla or •.,> '^.•.•• �- .:1 60
improve for purynse of ole.). 508 - FINAL MECHANICAL
--------._...._..-------------------------------.._--- -----..-----------------------...._...----___..__......__._..-'------d.�::c:;rn_er--------'--......_
- :trownerp meP(Sec.7(am cxdusvdydPra'tlntwith Raidedro antro io ^^• _,;f:':
Lt.. me project(Sec.]044.Business air Professions Code:)The ver trmor's Irl✓;. V'.Si:I '.b:i H
Littve taw does not apply to of wmer,o!
PP Y propmY who builds ar improves crcrron.
_ .._ .eM.whoconlmeseclawuch.pmjats.wim.a.comnnor(q-liccnxd-puRuanbro.lite-..-._.._._...._...__._.___..__._.._.
Covmocto/a Lieeisse law n-tl,•-P.4 • c , t 1't:EC" _._-.. ..___..
.... .....i if .
- -' c ❑lam exempt uiidir Sic.-" '"`"" BRECfa.mis Ruon •-•J .1(i'.i.`i
Owner-'' Daierrc:•..a:•.1'c.aa::?-,'. i^y I',•;.
WORKER-S COMPENSATION DECLARATION
Ihereby riffitm,neva pe lsy N prcijury ox fthe follmain,aecluatia--
q�O L ht vein' 11 mei o n e Ceitifidote f Conuni'ic`self..for Worinal
ll Compensation as provided for by"Section-3]00-af-tie-labor Caae,-for'Ju
peHomaricer of the work for wNch this pcmdt u issue ,_-
❑1 MJe M 11 ma nu Windt Coe pcuation Insu dna'u Rq ntol Scat
37l the Labor Cade for the performvoce of tit oik'toi ht h th s pcmll u
isoea My�Worker',Compe admo l ae came d P 1 y u.Ee
er NAC r'@YtA - IinNo ' 'LULRGf-t3(i14 4'
.. CERTIFICATION F EREsllil FROM,WORKERS H _ t
lift,
" ;. COMPENSATIONINSURANCE a""
F
).,lfai Mir inion end nes be corAfive °d if the permis for one hundred dollars '' ' ' ' 'tl
(SIW)a less)
I
,i'•€Ian fy viae i Ne pert rmmce of the at for which this pemul i sss yea 1
shall nes employ any person in any'manne(so as to become•iub)en to N<Works'rs 't
pp Cal form D ten ""'
NOTICETO APPUCANP If-efmr mvkip`thsCtnifcam'he aaywhauld
Is bjI1 the Wml Compenialo pre ons ofcre you a`, [•. t ' L?J
most
O fonhw tit amply Ib such prov sits.or tit permit shall be da d revoked
Zti .. _.. _...__ -_..- __ ... .._.-_... _._..__..__. .___.. _. ..._----._ ___ ----------
once
_-_
y JI:1*+ "t 'Cl1N5IRUCTION,LENDING AGENCY m s .. �,..LVt 1 ,..
"c'r lherc offmiih tthcRneconiwct on li do
by pp Lcncy fa die pbrfoirnance
of rite drk fee hl'ti this perm. s issued(S a JW]'Ct C) a.�'' i
t
� [� -rand<r's N1me'a"'-•'" •.•.. .• F,ua:.0 ..._
5 1. t t: .iJ(•
-
n,•c;l cm Iy iha 1 have roe Nis epplicauon aiM tux sha Ne above MamWov is
W'c[s
0edvieiia eLRe a colwiM ellcitMautordinanes a aax lweclums
erupon
,�c6,t the ebo_ve-mentioned pioperry fpr smppcu°n purp°xs•.......:...... ...i...,,,,a.._._
yAi IWe)7jree ro oven inafariui%end kFeR hamdcsi Ne City of Cupertino nyeina
rn 1 abiliucs y dgmenu,cows arW espenxs;wh ch may a y,wey accryc aya'rut said
C.J Ze C;Iy',iwa q ince df crc Ynol PL of$is pcmur t" L
Rl:IC i\DER �QSA.\OWI. \ >r\sT(H hLL\OC T�"c I
'SQVRC�u1.ATlc1'1 t ' Issued by: Date
HAZARDOUS TE ---6xL
u!der ed by mac iia Mumc pal Cod D le re y Re-roofs
n i
RIALS O15CLOSU
d REI s a 4 s c.
'ksW'n cr PPIane m furvre Wildfink occupant aorc or h die huadwa are al .. .Type Of Roof
n Ors )-t r e Chep¢ 9112 and cre pHNcr nd Safer'
Code,Sect on 833]1
_ .All.roofs shall be ins ected. non to any.roofing matenal.being installed-_,,.,_„_,.....
: : P P Y I g i
+ w Wdlm appi� o r Rwda;nearopa to eq ipmemo am aswhlch If a roof is insialled'wi[hout first obtaining an'inspecuon;I agiee'tolremove
mtil harArd s coma t u aefnrA by the B y Arte Air QuJ ry Management ,
gi,a el all new matenals fo;,inspection.-Applicant understands and will.cQmply,with
all non-point source regulations:,.,
.1�'�)he x rtaE!�he:haoardou amneli rtgmrcmenu ander CTepur'695:of the '
Cdhfomia Nulcr&'Sa(oyCade:SadonsSWS:1SSJ3 eMSS3a:luMcrsund that ..._ _._ .___.__ .._.._—..__ -__-_ .__ __....-..._.. .__... ... . ...... .-._. _. ....__._ _ ..-_
port Ib 1 ry t wufy,the t l .'
time o!a Cenifil of
s ace ca dao nota d haR e t noes inn n u m,res
ouvput f L e req.rc nu lueh mon be ma pndr myiss
y i r _Signature of Applicant Date---.
C,m e thorn aegq t ',,.- z=:'� �aell�p All roof coverings to be Class"B or bett6t
' I
.- -OFFICE .__. . ._.._...-__. ...._. _. - . .. . ... _.... . _
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